[Long-term functional results after macular hole surgery. Results of a prospective study]. / Funktionelle Langzeitergebnisse nach Makulaforamenchirurgie. Ergebnisse einer prospektiven Studie.

PURPOSE: This study reports on the long-term results of macular hole surgery with peeling of the ILM. METHODS: A total of 88 consecutive patients (71 female, 17 male, mean age 67 years) were prospectively evaluated. All patients underwent a standard pars plana vitrectomy with removal of the ILM and an intraocular gas tamponade. Preoperatively, as well as on each follow-up visit, a clinical examination including measurement of best corrected visual acuity, Goldman perimetry, and OCT was performed. RESULTS: The mean postoperative follow-up was 49 months; 83 (94%) patients were pseudophakic at the last examination. Anatomic closure was achieved in 84 (95%) patients. No late reopening of the macular hole was observed. Best corrected visual acuity improved in 82 patients (93%), remained unchanged in 2, and deteriorated in 4 patients. Best corrected visual acuity improved from a median of 0.2 preoperatively to a median of 0.6 postoperatively (p<0.001). Duration of symptoms as well as low preoperative visual acuity had no significant impact on anatomic and functional success. CONCLUSIONS: Macular hole surgery leads to good functional and anatomical results, even in the long term. A long history of visual impairment and low visual acuity before surgery are not contraindications to surgical intervention.

[Preoperative scanning laser ophthalmoscopy: findings in idiopathic macular foramen]. / Präoperative Scanning-Laser-Ophthalmoskopie. Befunde bei idiopathischem Makulaforamen.

BACKGROUND: The aim of our study was a detailed morphological and functional assessment of macular foramen stages II-IV by scanning laser ophthalmoscopy (SLO) and fundus perimetry including a correlation with clinical findings. METHODS AND MATERIALS: Included in this prospective study were 78 patients where SLO imaging and fundus perimetry were performed with the SLO-105 (Rodenstock) prior to pars plana vitrectomy for macular foramen on one eye. Both the size and shape the of macular foramen were assessed. Deep (0 dB) and relative (12 dB) scotomata were tested using the Goldmann II stimulus in the 20 degrees field of the SLO. Imaging was performed with the infrared laser and confocal aperture C2. RESULTS: The size of macular foramen ranged from 140 microns to 800 microns (median: 420 microns) and 20 (26%) had irregular, polycyclic borders. In 21 patients (27%) a bright sector could be seen just outside the hole. Deep scotomata were notably smaller than the visible macular hole in 4 patients (6%) and 18 deep scotomata (25%) extended beyond the hole. There was a weak inverse correlation between the size of deep, relative scotomata and the diameter of the macular holes with the visual acuity (r = -0.46; r = -0.39 or r = -0.53), but no correlation with the duration of symptoms could be demonstrated. CONCLUSION: Polycyclic borders were seen as a new feature of some idiopathic macular foramen. This may be due to asymmetric traction or adhesions on the macular area. Also, deep scotomata either smaller or larger than the visible macular hole were found.

Macular changes after peeling of the internal limiting membrane in macular hole surgery.

PURPOSE: To report the incidence of macular changes following pars plana vitrectomy with peeling of the internal limiting membrane (ILM) for idiopathic macular hole. DESIGN: Prospective consecutive series. METHODS: In a prospective study 105 eyes of 105 patients underwent vitrectomy for idiopathic macular holes. Surgery consisted of a standard three-port vitrectomy, induction of a posterior hyaloid detachment, removal of epiretinal membranes including the ILM, fluid-air exchange and intraocular gas tamponade (15% hexafluoroethane (C2F6) gas mixture) followed by head-down positioning for at least five days. No adjuvants were used during surgery. In addition to the clinical examination, static microperimetry using a Rodenstock scanning laser ophthalmoscope (SLO-105) was performed pre- and 6 or 12 weeks postoperatively. The stimulus size was 0.2 degrees (Goldmann II), intensities employed were 0 and 12 dB. For all tests, 20-degree fields were used. RESULTS: Anatomic closure of macular holes was achieved in 92 (87.6%) of 105 patients by one operation. Eight patients underwent a successful second procedure. The closure rate after two operations was 95.2%. Best corrected visual acuity increased from a median of 0.2 (range 0.05 to 0.5) preoperatively to a median of 0.5 (range 0.05 to 1.0) postoperatively. Anatomical macular changes were found in 8 (7.6%) patients: There were two cases of macular edema following secondary cataract extraction and six cases of retinal pigment epithelium changes. Formation of postoperative epiretinal membranes or late reopenings were not noted. Small, mostly asymptomatic paracentral scotomata were seen in 59 (56.2%) of 105 patients. CONCLUSION: Anatomical changes of the macula following vitrectomy with removal of the ILM are infrequent. However, paracentral scotomata observed in our series might be caused by a trauma to the nerve fibers during ILM peeling. To achieve reliable results a standardized procedure for microperimetry should be developed.

Indocyanine green-assisted peeling of the internal limiting membrane may cause retinal damage.

PURPOSE: To demonstrate possible retinal damage caused by indocyanine green dye for staining of the internal limiting membrane in surgery for idiopathic macular hole. METHODS: Consecutive interventional case series. We report on the ultrastructural findings of the internal limiting membrane in 10 eyes of 10 patients. RESULTS: All specimens revealed not only the internal limiting membrane, but also some small amounts of retinal elements, such as the plasma membrane of Müller cells and other undetermined structures. This indicates a cleavage plane not exactly at the inner undulating aspect of the internal limiting membrane but within the innermost retinal layers. CONCLUSION: Dilutions of indocyanine green as recommended in the literature may alter the structure of the retina to some degree. Possible factors responsible for this inadvertent action may include (1) concentration, (2) osmolarity pH, (3) time of tissue contact, and (4) mechanical factors from more forceful traction during peeling. Although functional consequences of these findings remain unclear as yet, factors that may induce damage to the innermost retina should be elucidated.

Peripheral visual field defects after macular hole surgery: a complication with decreasing incidence.

AIM: To prospectively evaluate peripheral visual fields after vitrectomy for idiopathic macular holes. METHODS: Goldmann perimetry was performed in 105 patients before, as well as 6 weeks and 12 months after macular hole surgery. RESULTS: Only one patient (< 1%) with a stage III macular hole developed an asymptomatic postoperative visual field defect. The scotoma was wedge-shaped, peripherally located in the temporal quadrant, and remained unchanged during the following 12 months. CONCLUSION: Peripheral visual field defects after macular hole surgery can be a complication of very low incidence. A rather low pressure set during air-fluid exchange as well as special aspects of the surgical technique may be responsible for this low incidence of peripheral visual field defects.

Paracentral scotomata: a new finding after vitrectomy for idiopathic macular hole.

AIMS: To report the occurrence of paracentral scotomata after pars plana vitrectomy for idiopathic macular holes. METHODS: In 15 patients static microperimetry using a Rodenstock scanning laser ophthalmoscope (SLO-105) was performed preoperatively and 6 or 12 weeks postoperatively (stimulus size 0.2 degrees (Goldmann II), employed intensity 0 and 12 dB, 20 degrees fields in all tests). Surgery consisted of standard three port vitrectomy including removal of epiretinal membranes and the inner limiting membrane. RESULTS: Postoperative paracentral scotomata were detected in areas that were tested normally before surgery. They were mostly located temporally and/or inferiorly and often appeared like nerve fibre bundle defects. The greatest dimension varied from 1.2 degrees to 4.0 degrees (360-1200 microm), smallest dimension from 0.25 degrees to 2.0 degrees (75-600 microm). In three patients more than one scotoma was observed. CONCLUSION: Small, mostly asymptomatic, paracentral scotomata as a complication after vitrectomy for idiopathic macular hole have not been reported in the literature so far. Whether they are caused by trauma to the nerve fibres during surgery or other factors remains unknown.